Provider Demographics
NPI:1417014986
Name:CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF RHEUM
Entity Type:Organization
Organization Name:CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF RHEUM
Other - Org Name:CHILDREN'S ASSOCIATED MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:KIMMONS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:858-966-8567
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4800
Mailing Address - Country:US
Mailing Address - Phone:858-309-6303
Mailing Address - Fax:858-309-6301
Practice Address - Street 1:8110 BIRMINGHAM WAY
Practice Address - Street 2:BUILDING 28
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2758
Practice Address - Country:US
Practice Address - Phone:858-966-8082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S SPECIALISTS OF SAN DIEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-03
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric RheumatologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR006886CMedicaid
CAW13774Medicare ID - Type UnspecifiedMEDICARE GROUP PROV#